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Br Dent J 2018; 225: 757–761 https://doi.org/10.1038/sj.bdj.2018.862

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We have seen, as covered in the recent media explosion about the state of British children's teeth, that dental decay is the number one reason for children to undergo general anaesthetic. As dental professionals many of us will see children with carious dentitions regularly. In most cases, well executed prevention, education and high quality clinical treatment will restore their oral health. However, things get a bit more complicated when we consider the concept of dental neglect.

Dental neglect is a grey area which is often misunderstood. In primary care, we have time to explore the child's background, follow their progress with increased recall intervals whilst having the ability to examine the attitudes of their guardians. Not all decay is indicative of child neglect, and not all child neglect will involve dental decay. Rather, other features in combination with the clinical picture, such as failure to seek treatment and continual ignorance of advice, would result in potential referrals to the local child safeguarding team.

Unfortunately, there has been a proven lack in clinician confidence in referring cases of dental neglect. Further difficulty arises for our colleagues working within maxillofacial secondary care departments, as children who could be at risk of dental neglect are presenting as emergency admissions to hospital. They might only get the opportunity to view the child at one moment in time, complicating the decision as to whether it is proper to involve social services.

Through this retrospective audit published in the BDJ, Schlabe and co-authors demonstrate the possible link between acute dento-facial infection and wider neglect. The audit reviewed 27 children, aged 16 or younger, who had an emergency general anaesthetic within King's College Hospital for treatment of an odontogenic infection. Eleven (40%) of the children were already known to social services, and three of these children had a new referral created due to fresh concerns. Out of the 16 children that were not known to social services, the team referred one child.

This audit supported the development of a local safeguarding referral pathway for children presenting with dental or maxillofacial space infection. This pathway aims to aid in the decision making process regarding social service referrals, by considering the clinical features alongside risk factors for wider child neglect.

It is everyone's responsibility to detect and refer potential cases of child neglect. As well as potentially life-threatening consequences, dental neglect might indicate wider child neglect, and so any concerns should be escalated appropriately. After all, why would we want to allow neglect to infect?

Author Q&A with Marielle Kabban and Kathleen Fan King's College Hospital

Were you surprised by any of the results?

We had not anticipated the strong link between our paediatric patients presenting with severe dento-facial infection and being already known to social services.

What were the limitations to your study?

This is a small study looking at patients with particularly severe infection secondary to dental decay.

Can practical steps be taken using your findings to help identify cases of dental neglect?

Dentists are already aware of the link between dental decay and dental neglect. It is important that they are aware of the potential link between dental decal, dental neglect and overall neglect. Dentist need to feel confident about contacting their local safeguarding team to discuss worrying cases and shring information with other services, eg school nurses, health visitors and GPs.

Expert view

Christine Park

Senior Clinical University Teacher and Honorary Consultant in Paediatric Dentistry, Glasgow Dental Hospital and School and BSPD Deputy Safeguarding Representative

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In the UK one in ten children have experienced neglect.1 It is the most common reason for taking child protection action and can kill, or cause serious long-term effects to physical and mental health.2 It occurs when parents or carers are unable to meet a child's needs. Sometimes it may be because those with parental responsibility don't have the skills or the support they need, or sometimes it is due to other problems (eg mental health issues, drug or alcohol problems, domestic abuse, financial problems, poor housing or homelessness).2

Paediatric dento-facial infections are some of the more severe sequalae of untreated dental disease resulting in children having to undergo urgent or emergency incision and drainage procedures under general anaesthesia. As the British Society of Paediatric Dentistry points out in its policy document on dental neglect 'there may be a wide range of family, environmental, or service reasons why oral health needs are not met'.3 Dental caries per se is not indicative of dental neglect but should be considered when there is obvious dental disease (obvious to a lay person) especially where it has an impact on the child and practical care has been offered, yet the child has not returned for treatment. The types of situations that may be concerning in general practice include cases where the parents or carers have access to but persistently fail to obtain treatment for the child indicated by irregular attendance and repeated missed appointments, failure to complete planned treatment, returning in pain at repeated intervals or requiring repeated general anaesthesia for dental extractions.4

Everyone working in a universal service such as dentistry has an important role in providing early help to families where neglect is suspected. This can include talking to families about your concerns to understand the unmet need and referring to services that can help. By working with children, parents and carers we can do our bit to help get the right help at the right time to families and, thereby, help protect all children.